| NPI | 1568505972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501011595) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 120002030) |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2015-08-12 |